Vi,CHE 

SUiiUlUxi^    AIvL-.Tj/ii 

J?' 
TtiZ  UROIH 


M-  &V\W 


XYb 


Columbia  Statoem'tp 

College  of  fifipgirians  ana  gmrgeons 
linear? 


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in  2011  with  funding  from 

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http://www.archive.org/details/onsurgicalanatomOOvach 


ON  THE 


SURGICAL  ANATOMY 


OF 


ill   (SUBdDXH* 


AS   CONNECTED  WITH 


HERNIA  OF  THE  ABDOXfflEXff, 


BY 


ALEXANDER  F.  VACHE, 
OF  NEW-YORK. 


"  Da  mihi  numine  tuo  vinceie,  Apoho  ." 

PRINTED  BY  WILLIAM  GRATTAN, 

JVb.  8,  Thames-street, 

1825. 


fit 

,V/J 


AN 

INAUGURAL  DISSERTATION, 

ON    THE 

SURGICAL    ANATOMY 

OF 
SUBMITTED  TO  THE  PUBLIC  EXAMINATION  OF  THE 

PROFESSORS  AND  TRUSTEES 

OF   THE 

COLLEGE  OF  PHYSICIANS  AND  surgeons 

f  OF   THE 

UNIVERSITY  OF  NEW- YORK, 

WRIGHT  POST,  M.  D.  PRESIDENT, 

ON  THE  4tb  OF  APRIL,  1825, 
FOR  THE 

DEGREE  OF  DOCTOR  OF  MEDICINE. 


TO 

VALENTINE  MOTT,  M.  D. 

PROFESSOR  OF  SURGERY 

IN   THE 

UNIVERSITY  OF  THE  STATE  OF  NEW-YORK, 

kc.  Sec.  kc. 

WHOSE   SPLENDID   DISSECTIONS    OF   THE  ANATOMY  OP  THE  GROIN, 

AND 

WHOSE   DEMONSTRATIONS    AND   ILLUSTRATIONS 

OF    THE 

HERNIA  OF  THE  ABDOMEN, 

DISTINGUISH    HIM    ALIKE   AS    THE    PRACTICAL   SURGEON 
AND    SCIENTIFIC    LECTURER, 

THIS  DISSERTATION 

IS   MOST   RESPECTFULLY   PRESENTED, 
BY    HIS    PUPIL, 

THE  AUTHOR. 


vmavMau 

The  study  of  Surgical  Anatomy,  or  the 
acquirement  of  the  connexion  and  relative 
situation  of  one  part  with  another  in  relation 
to  surgical  operations,  is  one  of  the  most  im- 
portant requisites  which  operative  surgery  de- 
mands for  its  accomplishment.  It  is  with  this 
knowledge  that  the  surgeon  fearlessly  performs 
the  boldest  of  operations ;  it  is  this,  in  dark 
deep-seated  places  which  distinguishes  one 
part  from  another,  and  guides  the  knife  cor- 
rectly, and  with  perfect  safety  to  the  patient. 
It  is  this  knowledge  alone,  which  can  give  con- 
fidence to  the  operator,  and  save  him  from  hesi- 
tation, confusion,  and  error.  In  short,  it  is 
to  the  assiduity  and  perseverance  with  which 
surgico-anatomical  and  pathological  investiga- 
tions have  been  pursued  by  the  votaries  of  these 
particular  sciences,  that  the  splendid  progress 
of  surgery  in  modern  days  can  alone  be  attri- 
buted. 


Vlll 


The  union  of  anatomy  with  pathology,  or  the 
knowledge  of  the  natural  state  of  our  organs, 
with  the  various  diseases  to  which  they  are  sub- 
jected, can  alone  form  the  basis  for  correct 
reasoning  on  disease,  and  point  out  the  most 
rational  method  of  cure  with  which  modern 
surgery  may  be  enriched. 

As  such,  I  have  selected  the  Surgical- Ana- 
tomy of  the  Groin,  as  connected  with  Hernia, 
for  the  subject  of  my  dissertation ;  not  however, 
with  the  wish  of  becoming  an  author,  but  solely 
with  the  view  of  conforming  with  one  of  the 
requisites  for  the  obtaining  of  a  degree.  Should 
I  succeed  in  elucidating  the  most  trivial  parti- 
cular relative  to  this  highly  important  piece  of 
surgical  anatomy,  which  I  am  aware  has  already 
undergone  the  closest  investigations,  I  shall  be 
satisfied.  Should  I  fail,  no  disappointment  will 
follow. 


ESSAY  ON 
HSUNXA  ABDOMINIS, 


Hernia  is  the  protrusion  of  any  viscus  from 
its  natural  cavity.  Hernia,  as  a  class,  may 
very  properly  be  divided  into  three  orders,  viz. 

Hernia  Cerebri, 

Hernia  Thoracis, 

Hernia  Abdominis. 
To  the  last  we  confine  ourselves  exclusively. 

Hernia  of  the  abdomen  is  the  protrusion  of 
any  of  the  abdominal  viscera  from  their  natural 
cavity,  forming  an  external  tumour.  It  consists 
of  four  distinct  genera,  viz. 

Hernia  Inguinalis, 

Hernia  Femoralis, 

Hernia  Urnbilicalis, 

Hernia  Ventralis. 

Inguinal  hernia  always  protrudes  above  Pou- 
part's  ligament,  and  is  of  two  species,  viz. 
Direct  and  Indirect.     Direct,  when  it  comes 

1 


10 

directly  from  the  abdomen  through  the  externa! 
ring.  Indirect,  when  it  comes  indirectly  from 
the  abdomen  through  the  internal  ring,  follow- 
ing the  course  of  the  spermatic  cord,  and  most 
frequently  protruding  at  the  external  ring.  Fe- 
moral hernia  protrudes  below,  and  from  under 
Poupart's  ligament,  and  has  no  distinct  species, 
but  several  varieties.  Umbilical  hernia,  pro- 
trudes at  the  umbilicus.  Ventral  hernia,  pro- 
trudes at  any  point  not  peculiar  to  the  others. 
Besides  these,  there  are  hernise  protruding  from 
the  pelvic  foramina,  though  of  rare  occurrence, 
which  take  their  names  from  their  location. 
There  are  also  some  internal  herniee,  which  are 
not,  perhaps,  strictly  entitled  to  the  appellation 


BXSS2CTXON  OF  ?KS  PAXLTS  COCTCTECTZm 
WITH  XNCTOXXI AL  HXSRSrXA. 

The  subject  selected  for  this  purpose  should 
be  emaciated,  as  this  facilitates  the  dissection, 
and  permits  the  parts  to  be  shown  distinctly. 
A  male  is  preferable  for  inguinal  hernia,  and  a 
female  for  femoral ;  the  former,  however,  will 
answer  for  both  purposes. 


II 


The  subject  should  be  placed  on  a  common 
dissecting  table,  with  a  block  passed  under  the 
body  immediately  above  the  pelvis,  sufficiently 
high  to  put  the  abdominal  parietes  on  the 
stretch.  The  hair  is  now  to  be  shaved  from 
the  pubes,  and  then  an  incision  is  to  be  made 
from  the  upper  part  of  the  umbilicus  in  a  straight 
line  to  the  symphysis  pubis.  This  is  to  be 
intersected  by  another,  commencing  at  the  um- 
bilicus, and  continued  at  right  angles  with  the 
former,  sufficiently  far  on  the  back  to  allow  the 
anterior  and  lateral  parts  of  the  abdomen  to  be 
shown. 

The  dissection  is  to  be  carefully  commenced 
on  either  side,  at  the  angle  formed  by  the  inci- 
sions, being  particular  to  remove  the  integu- 
ments alone  ;  and  it  is  to  be  continued  until 
the  whole  flap  is  turned  off,  when  will  be  ex- 
posed to  view  the  Fascia  Superficialis. 

The  fascia  superficialis  is  a  firm,  dense, 
inelastic  membrane,  pervading  the  whole  body, 
lying  immediately  under  the  adipose  substance 
of  the  common  integuments,  and  thus  forming 
one  of  the  coverings  to  all  the  herniae  of  the 


12 


abdomen ;  consequently  it  should  be  particu- 
larly noticed. 

An  incision  is  now  to  be  made,  in  the  same 
manner  as  the  former,  and  this  fascia  is  to  be 
raised  cleanly  from  the  parts  beneath,  observ- 
ing particular  care  at  Poupart's  ligament,  with 
which  it  is  intimately  connected,  and  from  which 
it  cannot  be  easily  separated.  We  now  have 
exposed  to  view  the  external  oblique  muscle, 
and  Poupart's  ligament  terminating  its  lower 
external  boundary. 

Previous  to  describing  this  muscle,  it  will  be 
more  strictly  anatomical  to  observe  the  abdo- 
minal lines,  which,  however,  are  only  in  part 
brought  within  the  limits  of  this  dissection. 

The  line  a  alba  is  a  white  line,  reaching  from 
the  ensiform  cartilage  to  the  symphysis  pubis, 
and  is  formed  by  the  tendinous  insertion  of  the 
three  abdominal  muscles  into  their  fellows  of 
the  opposite  side.  About  midway  of  this  line 
is  to  be  observed  the  umbilicus,  a  cicatrix  formed 
by  the  separation  of  the  umbilical  cord. 


13 


The  linea  semilunaris  is  seen  on  the  outer 
edge  of  the  recti  muscles,  of  a  semilunar  shape, 
and  is  formed  by  the  fleshy  fibres  of  the  abdo- 
minal muscles  becoming  at  this  point  tendinous 
in  their  structure. 

The  LiNEiE  transversa  are  three,  sometimes 
four  tendinous  intersections  of  the  recti  mus- 
cles, running  across  at  right  angles  to  their  lon- 
gitudinal fleshy  fibres. 

We  now  proceed  to  the  consideration  of  the 
external  oblique  muscle,  and  successively  to  the 
remaining  muscles  of  the  abdomen  ;  annexing, 
however,  their  origin,  which  cannot  be  seen  in 
this  view  of  the  parts,  and  attaching  to  each  the 
points  connected  with  inguinal  hernia,  as  they 
appear  on  separate  dissection. 

Obliquus  externus  vel  descendens  abdo- 
minis, arises  from  the  outside  of  the  eight  lower 
ribs,  a  little  posterior  to  the  junction  with  their 
cartilages,  by  as  many  fleshy  digitations  with 
the  serratus  major  anticus  ;  being  connected, 
also,  with  the  pectoralis  major,  intercostales, 
and  latissimus  dorsi  muscles. 


14 


Its  fibres  run  obliquely  downwards  and  for- 
wards, becoming  tendinous  at  the  linea  semilu- 
naris. Inserted  fleshy,  into  the  outer  labium  of 
the  crista  of  the  ilium  ;  tendinous,  into  the  whole 
length  of  Poupart's  ligament,  by  what  is  called 
the  outer  column,  which  terminates  at  the  tube- 
rosity of  the  pubis,  in  contradistinction  to 
the  tendinous  fibres  which  separate,  and  are 
inserted  into  those  of  the  muscle  of  the  op- 
posite side,  at  the  symphysis  pubis,  called  the 
inner  column.  It  is  next  inserted  into  the 
whole  length  of  the  linea  alba  and  the  ensiform 
cartilage. 

By  the  separation  of  the  fibres  of  this  muscle, 
above  Poupart's  ligament,  an  opening  is  left  for 
the  passage  of  the  spermatic  cord  of  the  male, 
and  the  round  ligament  of  the  female,  permit- 
ting their  exit  from  the  oblique  canal.  It  has 
received  the  name  of  external  abdominal  ring, 
although  of  a  triangular  shape,  bounded  on  each 
side  by  the  two  tendinous  columns,  with  its 
apex  above  and  its  base  below,  formed  by  that 
part  of  the  pubis  between  the  tuberosity  and 
symphysis.  This  opening  can  most  generally 
be  traced  as  far  up  as  the  fleshy  fibres  of  the 


15 


muscle,  and  can  be  distinctly  observed  by  a 
dark  shade  from  the  absence  of  the  tendon, 
beneath  where  it  is  crossed  at  its  upper  part 
by  numerous  transverse  tendinous  fibres  bound- 
ing and  giving  strength  to  it  above.  That  the 
parietes  should  not,  however,  be  weakened  by 
this  deficiency  of  tendinous  matter,  there  are 
numerous  layers  of  fibres  sent  off  from  the  sur- 
rounding parts,  crossing  each  other  in  all  direc- 
tions, and  are  intimately  connected  with  the 
tendon  of  the  muscle.  Besides  these,  this 
part  is  also  strengthened  by  a  triangular  ten- 
dinous portion  furnished  by  the  tendon  of  the 
opposite  side,  extending  from  the  symphysis 
to  the  tuberosity  of  the  pubis.  This  can  be 
seen,  on  raising  the  tendon  of  one  side, 
showing  the  fibres  from  the  opposite  muscle 
beneath. 

It  has  been  advanced,  that  this  additional 
tendon  of  the  muscle  from  the  opposite  sider 
besides  strengthening  the  insertion  of  the  inter- 
nal oblique  and  transversalis  into  the  pubis, 
also,  when  the  abdominal  muscles  and  linea 
alba  are  stretched,  closes  up  a  greater  portion 
of  the  external  ring ;  accounting,  in  this  man- 


16 


ner,  for  the  rare  occurrence  of  direct  inguinal 
hernia.* 

This  aperture  in  the  male  is  about  an  inch 
in  length  ;  in  the  female,  about  half  an  inch  : 
the  round  ligament  being  smaller,  and  less  lia- 
ble to  suffer  from  the  contraction  of  the  muscle. 

The  use  of  the  external  oblique  muscle  is  to 
assist  to  sustain  the  abdominal  viscera,  to  bend 
the  body  to  one  side,  and  when  both  act,  to  ap- 
proximate the  chest  to  the  pelvis :  but  when 
the  pelvis  is  fixed,  it  draws  down  the  ribs,  be- 
coming a  muscle  of  expiration.  It  also  assists 
the  voiding  of  fceces  and  urine,  by  pressure  on 
the  abdominal  and  pelvic  viscera. 

The  dissection  can  now  be  continued  on  the 
same  side  ;  but  it  is  much  better  to  dissect  the 
opposite  precisely  as  the  former,  that  the  one 
may  remain  unmolested,  while  the  other  must 
necessarily  be  disturbed  for  an  inspection  of 
the  parts  beneath.  This  leaves  on  one  side 
the  external  parts  in  situ,  while  the  other  de- 

*  Professor  Colles',  of  Dublin,  Treatise  on  Surgical  Anatomy. 


17 


monstrates  its  connexion  and  relative  situation 
with  those  within,  and  also  adds  much  to  the 
beauty  and  neatness  of  the  view. 

After  this  is  accomplished,  an  incision  is  to 
be  made  on  either  side,  of  a  semicircular  form, 
extending  from  a  little  above  the  external  ring, 
so  that  it  may  be  preserved,  and  ending  it  a 
little  within  the  termination  of  the  tendinous 
fibre  into  those  of  a  fleshy  structure.  The  ten- 
dinous flap  is  to  be  raised  from  the  muscle  be- 
low, which  will  expose  to  view  the  lower  margin 
of  the  internal  oblique  muscle. 

Obliqdus  internus  vel  ascendens  abdomi- 
nis, arises  fleshy  from  the  outer  third  of  Pou- 
part's  ligament,  and  from  the  whole  length  of 
the  spine  of  the  ilium,  between  the  outer  and 
inner  labia ;  tendinous  from  the  back  part  of 
the  os  sacrum,  and  from  the  transverse  proces- 
ses of  the  three  last  lumbar  vertebra?.  The 
fibres  ascend  obliquely  upwards  and  forwards 
to  be  inserted  into  the  lower  edges  of  the  car- 
tilages of  the  five  false  ribs,  by  as  many  fleshy 
slips.  Becoming  tendinous  at  the  linea  semi- 
lunaris, it  divides  into  two  lamina?,  forming  a 

2 


18 


sheath  for  the  rectus  muscle,  at  the  inner  edge 
of  which  the  laminae  again  unite  and  terminate 
into  the  whole  length  of  the  linea  alba,  inser- 
ted, also,  into  the  symphysis  pubis,  and  into  the 
ensiform  cartilage.  Its  use  is  similar  to  that 
of  the  former,  acting  in  a  reverse  direction. 

The  next  muscle  coming  within  this  dissec- 
tion, and  which  must  be  particularly  noticed,  is 
the  Cremaster,  This  muscle  always  forms  a 
covering  to  an  indirect  hernia,  and  when  suffi- 
ciently strong  to  be  seen,  distinguishes  it  from 
a  direct. 

The  cremaster  arises  from  Poupart's  liga- 
ment, just  before  the  internal  oblique  commen- 
ces its  attachment,  and  has,  by  many,  been 
described  as  additional  fibres  furnished  by  that 
muscle.  The  cremaster  descends  upon  the 
spermatic  cord  from  the  inguinal  canal,  and  is 
inserted  into  the  tunica  vaginalis  of  the  testicle, 
upon  which  it  spreads,  and  is  insensibly  lost. 
Its  use  is,  to  suspend  and  draw  up  the  testicle, 
and  to  compress  it  in  the  act  of  coition,  facili- 
tating the  passage  of  semen  along  the  vas 
deferens.     This  muscle  is  stronger  and  more 


19 


visible  from  the  presence  t)f  hernia  of  some 
duration. 

The  fibres  of  the  internal  oblique  can  now 
be  detached  from  their  origin,  leaving  the  ere- 
master  in  its  situation,  as  far  as  the  external 
incision,  and  turned  up  so  as  to  expose  the 
transversalis  beneath,  and  to  allow  of  its  fur- 
ther dissection  when  necessary. 

Transversalis  abdominis  arises  tendinous. 
but  soon  becomes  fleshy,  from  the  inner  surfaces 
of  the  six  or  seven  lower  ribs,  and  is  connected 
to  the  diaphragm  and  intercostal  muscles  ;  also, 
from  the  transverse  processes  of  the  last  dorsal 
and  four  superior  lumbar  vertebrae,  from  the 
inner  labium  of  the  crista  of  the  ilium,  and  from 
Poupart's  ligament,  one  third  its  length  from 
its  origin.  The  iibres  run  across  the  abdomen, 
become  tendinous  at  the  linea  semilunaris,  and, 
passing  behind  the  rectus,  are  inserted  into 
the  symphysis  pubis,  into  the  linea  alba,  and 
into  the  ensiform  cartilage.  Its  use  is,  to 
support  and  compress  the  abdominal  viscera, 
and  is,  perhaps,  the  proper  constrictor  of  the 
abdomen. 


20 


Previous  to  proceeding  to  the  dissection  of 
the  transversalis  muscle,  as  immediately  con- 
nected with  the  subject,  it  may  be  well  to  ob- 
serve the  situation  of  the  two  remaining  pairs 
of  muscles  of  the  abdomen,  the  recti,  and  pyra- 
midales.  They  require  no  dissection,  as  they 
can  be  sufficiently  observed  through  the  sheath 
which  contains  them. 

Rectus  abdominis  arises  tendinous  from  the 
ligament  of  the  cartilage  which  joins  the  ossa 
pubium  to  each  other.  It  soon  becomes  fleshy, 
and  its  fibres  ascend  broad  and  flat,  parallel  to 
the  linea  alba,  to  be  inserted  into  the  cartilages 
of  the  three  inferior  true  ribs,  and  into  the  ensi- 
form  cartilage.  Its  fibres  also  frequently  inter- 
mix with  the  pectoralis  major  muscle.  Its  use 
is  to  compress  the  fore  part  of  the  abdomen,  to 
draw  down  the  ribs  in  expiration,  to  bend  the 
body  forwards,  and  to  raise  the  pelvis. 

This  muscle  is  generally  divided  by  three 
transverse  tendinous  intersections,  into  nearly 
three  equal  portions,  between  its  upper  extre- 
mity and  the  umbilicus,  and  there  is  frequently 
a  half  intersection  between  it  and  the  pubes. 


21 


These  seldom  penetrate  the  thickness  of  the 
muscle,  but  adhere  firmly  to  the  anterior  part 
of  the  sheath,  and  very  slightly  to  the  poste- 
rior layer.  By  the  tendinous  intersections,  it 
is  enabled  to  contract  at  any  of  the  interme- 
diate spaces,  and  by  its  connexion  with  the 
other  muscles  it  is  kept  in  its  place. 

Pyramidalis  is  enclosed  within  the  same 
sheath,  and  arises  in  common  with  the  rectus. 
It  is  inserted  by  an  acute  termination,  about 
midway  between  the  pubes  and  umbilicus.  Its 
use  is  to  assist  the  lower  part  of  the  rectus. 
This  muscle  is  not  always  found. 

The  transversal  is  muscle  can  now  be  detach- 
ed from  its  connexions  below,  and  dissected 
neatly  from  the  fascia  beneath,  sufficiently  far 
up  to  expose  to  view  the  internal  abdominal 
ring,  which  will  complete  all  the  dissection  ne- 
cessary for  the  abdominal  muscles,  and  enough 
of  the  fascia  transversalis  for  surgical  purposes. 

The  fascia  transversalis  is  a  membranous 
expansion  of  various  density  ;  arising  from  Pou- 
part's  ligament,  and  immediately  investing  and 


22 


accompanying  the  peritoneum  throughout  its 
extent,  it  would  seem  to  give  additional  strength 
to  that  delicate  membrane,  and  defend  it  from 
friction  during  muscular  action.  In  this  fascia 
we  find  the  internal  abdominal  ring.* 

The  internal  abdominal  ring  is  the  aper- 
ture through  which  the  spermatic  cord  of  the 
male  and  the  round  ligament  of  the  female 
make  their  first  exit  from  the  abdominal  cavity. 
It  is  situated  about  midway  between  the  supe- 
rior spinous  process  of  the  ilium  and  symphysis 
of  the  pubes.  To  see  this  opening  distinctly, 
it  is  necessary  to  remove  the  Cylindrical  pro- 
cess, a  process  sent  from  its  edges  less  dense 
than  the  fascia  itself,  and  embracing  and  ac- 
companying the  cord  to  the  external  ring. 

On  raising  the  cord  and  opening  the  cylin- 
drical process,  we  can  then  observe  the  inter- 
nal ring  to  be  rather  oval  than  round,  with  its 
longest  diameter  placed  perpendicularly  to 
Poupart's  ligament  having  well  defined  bor- 


*  We  shall,  for  surgical  purposes,  consider  these  fasciae  as  procpsses 
of  Poupart's  ligament,,  although  not  anatomically  correct. 


23 


ders  formed  by  two  fibrous  columns  of  tlie 
fascia  itself. 

These  columns  do  not  run  into  each  other, 
but  decussate  ;  the  outer  one  crossing  the  inner 
in  a  direction  towards  the  pubes,  and  termi- 
nating in  the  superior  edge  of  Poupart's  liga- 
ment. The  inner,  having  a  direction  backwards 
and  outwards  towards  the  spine  of  the  ilium, 
is  lost  in  the  posterior  edge  of  the  same  liga- 
ment near  to  the  mouth  of  the  crural  sheath. 

These  margins  are  frequently  of  a  strong 
tendinous  structure,  and  quite  sufficient  to  effect 
a  powerful  strangulation  at  the  neck  of  a  her 
nial  tumour. 

The  remaining  parts  to  be  noticed,  are  the 
spermatic  cord  and  epigastric  vessels,  which 
ought  to  be  particularly  observed  from  the  inti- 
mate connexion  they  have  with  the  operations 
performed  at  the  groin. 

The  spermatic  cord  is  made  up  of  the  artery, 
vein,  absorbents,  and  excretory  duct  of  the  tes- 
ticle.    It  also  receives  branches  from  the  in- 


24 


ternal  iliac  and  epigastric  arteries;  and  nerves, 
from  the  second  lumbar  and  renal  and  aortic 
plexuses. 

The  spermatic  artery  arises  from  the  late- 
ral parts  of  the  aorta,  a  little  above  the  inferior 
mesenteric,  and  taking  a  course  along  the  psoas 
muscles,  crosses  the  ureter  and  reaches  at 
length  the  internal  abdominal  ring ;  here  it 
enters  into  the  composition  of  the  cord,  accom- 
panies it  to  the  scrotum,  disperses  upon  the 
epididymis  of  the  testicle,  and  performs  the 
secreting  of  the  semen. 

The  spermatic  vein  passes  from  the  testicle 
along  the  cord  into  the  abdomen,  and,  opposite 
to  the  lower  end  of  the  kidney,  ends  in  a  single 
trunk,  which  proceeds  onward ;  that  on  the  right 
side,  terminating  into  the  vena  cava ;  that  on 
the  left,  at  right  angles  into  the  left  cmulgent 
vein.     These  veins  have  many  valves. 

The  vas  deferens  is  a  cylindrical,  cartilagi- 
nous tube  for  conveying  the  semen  from  the 
testicle  to  the  urethra.  It  commences  at  the 
posterior  and  inferior  part  of  the  epididymis. 


25 


and  takes  a  course  along  the  back  part  of  the 
cord  until  it  reaches  the  internal  ring,  when  it 
separates  from  it  and  passes  downwards  and 
backwards  along  the  psoas  muscle,  and  is 
attached  to  the  side  of  the  bladder.  It  then 
crosses  the  ureter  and  proceeds  from  behind 
forwards,  between  the  vesiculse  seminales,  until 
it  reaches  the  prostate  gland,  where  it  unites 
with  the  duct  of  the  vesiculse  seminales,  forming 
a  tube  about  an  inch  in  length  common  to  both. 
This  perforates  the  prostate  gland,  and  opens 
into  the  urethra  by  the  side  of  the  veru  monta- 
num.  The  covering  of  the  spermatic  cord  is 
the  tunica  vaginalis,  with  the  cremaster  muscle 
spread  on  its  surface. 

The  tunica  vaginalis  is  a  process  of  the 
peritoneum,  accompanying  the  descent  of  the 
testicle  of  the  foetus  into  the  scrotum.  Pre- 
vious to  the  eighth  month,  the  testicle  is  within 
the  abdomen,  lying  below  the  kidney  upon  the 
psoas  muscle,  covered  anteriorly  and  laterally 
by  the  peritoneum  ;  about  this  time  it  descends, 
receiving  direction,  as  is  supposed,  from  a  liga- 
mentous substance  named  Gubernaculum.  In 
consequence  of  more  peritoneum  being  brought 

3 


26 


down  into  the  scrotum  than  was  in  close  adhe- 
sion with  the  testicle,  we  have  a  loose  or  re- 
flected portion  not  adhering  to  it,  constituting 
the  cavity  of  the  tunica  vaginalis.  This  pro- 
cess of  peritoneum  may  be  divided  into  two 
portions ;  the  tunica  vaginalis  of  the  cord,  which 
has  its  cavity  obliterated  soon  after  birth  by  ad- 
hesion f  and  the  tunica  vaginalis  of  the  testicle 
which  remains  disconnected,  excepting  at  its 
posterior  part,  and  secretes  a  lubricating  fluid. 

The  cremaster  muscle,  if  it  has  not  been  re- 
moved, can  now  be  distinctly  seen,  taking,  from 
its  origin,  a  course  towards  the  external  ring, 
along  the  inferior  edge  of  the  cord,  and  is  lost 
on  the  tunica  vaginalis  testis. 

The  epigastric  artery  is  about  the  size  of 
a  crow  quill,  and  arises  from  the  external  iliac 
as  it  is  about  passing  under  the  crural  arch.  It 
runs  upwards  and  inwards,  from  one  to  two 
inches,  between  the  fascia  transversalis  and 
•peritoneum ;  it  then  perforates  the  fascia  ob- 
liquely and  runs  anterior  to  it.     A  little  above 

*  When  this  does  not  occur,  a  passage  is  afforded  for  intestine,  con- 
stituting the  hernia  congenita. 


27 


this,  it  penetrates  the  posterior  sheath  of  the 
rectus ;  and  near  the  umbilicus,  it  enters  the 
substance  of  that  muscle  previous  to  its  meet- 
ing with  the  internal  mammary  artery. 

It  thus  takes  a  course  between  the  two  rings, 
on  the  inner  edge  of  the  internal  ring,  and  on 
the  outer  edge  of  the  external  ring.  In  the 
inguinal  canal  it  gives  off  a  branch  to  the 
spermatic  cord ;  and  within  the  sheath  of  the 
rectus  it  supplies  lateral  branches  to  that 
muscle. 

This  artery  has  been  found,  and  not  unfre- 
quently,  to  arise  from  the  external  pudic,  also 
from  the  arteria  profunda  femoris.  Occasion- 
ally it  arises  high  up  from  the  external  iliac,  it 
then  takes  a  course  downwards,  then  forwards 
and  upwards,  to  pass  in  its  usual  direction. 
Doctor  Monro  mentions  a  specimen,  in  which 
it  arose  from  the  obturator,  and  ran  upwards  and 
inwards  to  the  rectus  muscle.  There  are  also 
some  other  uncommon  origins  mentioned,  but 
they  so  seldom  occur,  if  at  all,  as  to  be  hardly 
worth  acknowledging. 


m 


The  only  remaining  artery  to  be  known  and 
described,  as  connected  with  hernia,  is  the 
obturator.  This  can  be  examined  at  any  future 
time,  and  much  better  from  an  injected  prepa- 
ration ;  we  will  however  proceed,  while  on  the 
arteries,  to  a  description  of  it,  and  conclude  the 
particular  anatomy  of  this  part  of  our  subject, 
by  an  examination  and  description  of  the  peri- 
toneum. 

The  obturator  artery  is  generally  a  branch 
of  the  internal  iliac,  and  taking  a  course  a  little 
below,  and  nearly  parallel  to  the  brim  of  the 
pelvis,  passes  out  together  with  the  obturator 
nerve,  at  the  small  hole  in  the  upper  part  of  the 
obturator  ligament,  and  is  distributed  princi- 
pally to  the  upper  part  of  the  triceps  muscle* 

With  this  origin  and  course,  this  artery  does 
not  come  within  the  operations  for  inguinal  or 
femoral  hernia,  and  would  be  of  little  surgical 
importance.  It  however  has  various  origins, 
and  thus  becomes  of  some  consideration. 

It  not  unfrequently  arises  by  one  common 
trunk  with  the  epigastric  from   the   external 


29 


iliac,  and  occasionally  from  the  same  artery  by 
a  separate  trunk ;  with  this  origin  it  passes  by 
Gimbernat's  ligament,  and  is  connected  to  it 
by  cellular  substance.  It  has  also  been  seen 
to  come  from  the  femoral  artery,  within  the 
crural  sheath.  Mr.  Anderson  mentions  a  case, 
in  which  it  arose  from  the  ordinary  place,  and 
took  its  usual  course  ;  but  that  a  branch  was 
also  given  off  from  the  inside  of  the  external 
iliac  under  the  crural  arch,  that  took  a  curved 
direction  over  the  linea  ileo  pectinea,  and  joined 
the  former  a  little  behind  the  hole  in  the  obtu- 
rator ligament,  forming  a  common  trunk  to  be 
distributed  in  its  usual  manner.* 

The  various  origins  of  these  arteries,  unfor- 
tunately, cannot  be  ascertained  at  the  time  of 
operating,  and  thus  produce  no  variation  in  the 
mode  of  performing  it ;  but  will  account  for 
any  unusual  hemorrhage  which  may  take  place. 
Some  of  them,  however,  are  not  endangered, 
and  those  which  are  must  take  their  chance. 

The  peritoneum  is  an  expansion  of  dense 
cellular  membrane,  enveloping  the  abdominal 


*  See  System  of  Surgical- Anatomy,  p.  74. 


30 


viscera,  and  is  also  partly  reflected  upon  some 
of  the  contents  of  the  pelvis.  It  is  a  white, 
thin,  shining  membrane  of  the  serous  class  ;  its 
inner  surface  smooth,  secreting  a  serous  fluid 
for  its  lubrication,  and  forming  no  adhesions ; 
its  outer  surface  covered  by  the  fascia  transver- 
salis,  investing  the  inside  of  the  abdominal 
muscles,  the  posterior  part  of  the  abdomen,  and 
the  surface  of  the  several  viscera. 

The  peritoneum  superiorly  and  inferiorly 
lies  anterior  to  the  abdominal  viscera,  and  is 
loosely  attached  about  an  inch  or  two  above 
Poupart's  ligament  previous  to  its  descending 
to  line  the  posterior  part  of  the  abdomen. 
Thus,  when  a  hernia  occurs,  it  yields  readily 
to  the  pressure  of  the  protrusion,  and  accom- 
panies it  out  of  the  abdomen,  forming  the  her- 
nial sac. 

The  hernial  sac  is  a  common  covering  to 
all  the  abdominal  hernia,  with  the  exception  of 
congenital,  which  also,  it  will  be  remembered, 
is  a  process  of  the  peritoneum,  descending  with 
the  foetal  testicle,  taking  the  name  of  tunica 
vaginalis. 


31 


Having  completed  the  dissection  and  parti- 
cular anatomy  of  the  individual  parts,  as  they 
appear  in  regular  succession  under  the  knife? 
we  shall  now  take  a  general  review  of  them, 
connecting  the  relative  situation  of  one  with 
the  other,  their  connexion  with  inguinal  hernia, 
and  the  operation  for  its  relief  when  strangu- 
lated. 


OF  TH1   ©ESKTEIL&ii   ANATOMY  OF 

xNCNrinrA*  herexia. 

We  commence  by  restoring  the  parts  to  their 
natural  situation,  and  we  then  find,  by  begin- 
ning externally,  that  the  order  will  be  as  follows. 

First,  the  common  integuments.  Secondly, 
the  fascia  superficialis,  which  are  both  com- 
mon coverings,  and  always  form  the  two  ex- 
ternal coats  of  a  hernial  tumour.  Thirdly, 
the  external  oblique  muscle,  inserted  into  the 
whole  length  of  Poupart's  ligament,  contain- 
ing the  external  abdominal  ring  for  the  pas- 
sage of  the  male  or  female  cord,  and  through 
which  a  direct  inguinal  hernia  always  protrudes : 


32 


it  would  thus  have  for  its  coverings,  besides  the 
hernial  sac,  the  integuments  and  fascia  super- 
ficialis.  Fourthly,  the  internal  oblique  mus- 
cle ;  and  fifthly,  the  transversalis.  The  two 
last  form  the  superior  boundary  of  the  oblique 
canal,  and  by  the  former  extending  a  little 
lower  down  than  the  latter,  a  valvular  structure 
is  given  them,  rendering  additional  strength  to 
the  parts. 

The  oblique  or  inguinal  canal  can  now  be 
seen  to  be  the  space  between  the  external  and 
internal  abdominal  rings.  It  is  bounded  ante- 
riorly by  the  tendon  of  the  external  oblique 
muscle  ;  posteriorly  by  the  fascia  transversalis  ; 
superiorly  by  the  lower  edges  of  the  internal 
oblique  and  transversalis  muscles ;  and  infe- 
riorly  by  Poupart's  ligament.  In  this  canal, 
we  find  the  spermatic  cord,  or  the  round  liga- 
ment, covered  by  the  cylindrical  process  from 
the  internal  ring,  and  the  cremaster  muscle 
lying  at  its  lower  edge.  By  this  construction, 
the  oblique  canal  will  be  observed  superiorly 
to  be  of  a  valvular  structure,  adding  strength 
to  the  parietes  when  pressed  upon  by  the  vis- 
cera, and,  by  the  openings  for  the  passage  of 


35 


the  cord  being  removed  a  distance  from  each 
other,  a  greater  security  is  given  against  her- 
nial protrusions,  than  if  they  were  in  apposi- 
tion, allowing  a  direct  passage  to  the  cord  from 
the  abdomen. 

We  next  observe  the  fascia  transversalis  to 
be  in  close  contact  with  the  peritoneum,  and 
containing  the  internal  abdominal  ring  midway 
between  the  spine  of  the  ilium  and  symphysis 
of  the  pubis,  and  through  which  an  indirect 
hernia  always  protrudes,  carrying  the  cremas- 
ter  muscle  before  it,  and  in  this  additional 
covering  alone  differs  from  a  direct.  Through 
this  opening  the  cord  enters  from  the  abdomen 
into  the  oblique  canal. 

The  relative  situation  of  the  epigastric  artery 
and  vein  to  the  rings,  can  now  be  particularly 
observed,  the  vessels  running  on  the  inside 
of  the  internal  and  on  the  outside  of  the  external 
ring ;  consequently  the  division  of  the  stricture  at 
the  former  would  be  safely  performed  directly 
outwards,  and  at  the  latter  directly  inwards ;  but 
to  be  perfectly  safe,  for  fear  of  mistaking  the  spe- 
cies, it  can  be  divided  directly  upwards  in  both. 

4 


34 


We  now  observe  the  situation  of  the  sper- 
matic cord,  which  can  be  seen  occupying  the 
inferior  edge  of  the  internal  ring,  and  probably 
kept  in  its  place  by  the  weight  of  the  testicle. 
It  then  takes  an  oblique  direction  through  the 
inguinal  canal,  and  passes  out  at  the  external 
ring  accompanied  by  the  cremaster,  and  de- 
scends into  the  scrotum  to  the  testicle. 

The  situation  of  the  spermatic  cord,  as  re- 
gards direct  and  indirect  herniee,  is  generally  be- 
hind the  neck  of  the  sac  ;  there  are,  however,  oc- 
casional varieties  in  which  it  gets  before  it,  and 
sometimes  it  seems  to  be  divided  ;  the  vas  de- 
ferens getting  in  front  of  the  sac,  or  on  either 
side.     This  may  also  occur  to  the  blood  vessels. 

All  that  remains  to  be  noticed,  is  the  perito- 
neum, as  forming  the  hernial  sac. 


OPERATION  TOR  INGUIETAX.  HERNIA. 

The  operation  for  direct  inguinal  hernia  con- 
sists of  a  middle  incision  through  the  integu- 
ments, extending  the  whole  length  of  the  tu- 


35 


mour,  which  are  to  be  dissected  off,  when  the 
fascia  superficialis  beneath  will  be  exposed  to 
view.  The  fascia  superficialis  is  next  divided 
and  turned  off,  when  the  hernial  sac,  to  which 
we  have  now  come,  presents  itself.  Here  the 
knife  is  to  be  placed  flatwise,  and  this  coat  is 
to  be  cut  into,  delicately  and  cautiously ;  which 
is  generally  manifested  by  the  escape  of  a  quan- 
tity of  fluid,  although  this  does  not  always  occur. 

A  director  is  now  to  be  introduced,  and  the 
sac  freely  dilated,  by  placing  a  bistoury  in  its 
groove  and  cutting  outwards.  The  finger  is 
then  introduced  to  the  seat  of  stricture,  and  the 
nail,  if  possible,  insinuated  within  it.  A  probe 
pointed  bistoury  is  now  introduced  flatwise  on 
the  face  of  the  finger,  and  then  turned  up,  di- 
viding the  stricture,  to  be  perfectly  safe,  directly 
upwards. 

After  this,  the  contents  of  the  sac  should  be 
cautiously  examined,  and  particularly  the  stric- 
tured  part,  to  ascertain  if  there  are  any  ulcera- 
tions at  the  seat  of  strangulation,  and  whether 
it  be  returnable  or  not.  If  returnable,  and 
should  it  be  intestine,  the  gut  is  to  be  emptied 


M 


as  much  as  possible  of  its  contents,  and  the  last 
portion  protruded  passed  into  the  abdomen  first, 
and  so  successively,  until  it  shall  be  returned. 
If  not  returnable,  it  must  then  be  left  in  the 
sac,  and  subjected  to  one  of  three  alternatives. 
First,  by  leaving  it  entirely  to  nature,  and  allow- 
ing the  intestine  to  slough,  when  an  artificial 
anus  will  be  the  consequence.  Secondly,  by 
removing  the  intermediate  diseased  portion, 
and  bringing  the  edges  together,  connecting 
them  by  an  uninterrupted  suture  making  an 
attempt  at  union.  Thirdly,  by  introducing  one 
extremity  of  the  divided  gut  within  the  cavity 
of  the  other,  sewing  it  in  the  same  manner,  to 
accomplish  the  same  purpose  as  the  former. 

Should  these  attempts  fail,  there  is  still  ano- 
ther means  by  which  union  may  be  effected, 
independent  of  the  duration  of  an  artificial 
anus.  This  project  owes  its  origin  to  the  inge- 
nuity of  Mr.  Dupuytren.  It  consists  in  bring- 
ing each  extremity  of  the  divided  gut  in  lateral 
contact,  and  the  blades  of  a  bluntly  serrated 
forceps,  with  bulbous  extremities,  are  introdu- 
ced separately  into  the  open  mouth  of  each  in- 
testine.    The  forceps  is  then  locked,  making 


37 


of  course  the  most  pressure  at  their  extremi- 
ties, thus  promoting  the  absorption  of  intestine 
at  that  point,  and  establishing  a  communication 
between  the  two.  The  forceps  is  now  removed, 
and  when  the  fceces  pass  readily  through  the 
new  made  aperture,  the  extremity  of  each  in- 
testine is  to  be  united,  which,  when  accomplish- 
ed, is  returned  to  the  abdomen. 

Union,  I  think,  ought  always  to  be  attempt- 
ed, for  if  it  succeeds,  a  very  great  object  is  at- 
tained ;  if  it  fails,  the  patient  is  precisely  in 
the  same  situation  as  though  it  had  been  left 
to  nature. 

The  operation  for  indirect  inguinal  hernia 
does  not  differ  from  the  former,  when  the  pro- 
trusion reaches  the  external  ring,  with  the  ex- 
ception of  its  having  one  more  covering,  the 
cremaster  muscle.  This  protrusion,  however, 
does  not  always  reach  the  external  ring,  but 
occasionally  remains  within  the  inguinal  canal ; 
consequently  it  is  beneath  the  tendon  of  the 
external  oblique  muscle,  which  is  then  divided, 
and  exposes  the  fibres  of  the  internal  oblique, 
more  or  less,  according  to  the  muscularity  of 


38 


the  subject,  covering  the  hernial  sac,  which  is 
seen  after  turning  them  up. 

The  seat  of  stricture,  in  indirect  hernia,  may 
be  at  the  external  ring,  within  the  inguinal 
canal,  or  at  the  internal  ring  ;  that  must  be 
ascertained  at  the  time  of  operating ;  and  the 
same  rules  govern  this  precisely  as  do  the 
direct. 


DISSECTION  Or  THE  FARTS  CONNECTED 
WITH  FEMORAL  HERNIA. 

In  the  dissection  of  the  parts  connected  with 
femoral  hernia,  we  shall  follow  the  same  order 
as  observed  in  inguinal ;  that  is,  each  part  sepa- 
rately, as  it  appears  on  dissection ;  and  then 
collectively,  after  the  dissection  is  completed. 

For  this  purpose  an  incision  is  to  be  made, 
commencing  at  the  pubes,  a  little  within  the 
external  ring,  continuing  it  on  the  scrotum,  and 
terminating  it  about  six  inches  down  the  inner 
side  of  the  thigh.  The  dissection  is  to  be  com- 
menced at  the  upper  part,  and  the  integuments 


39 


alone  are  to  1>e  removed.  Next,  the  fascia 
superficialis  is  to  be  dissected  off,  removing 
with  it  the  superficial  glands  of  the  groin,  which 
are  enveloped  in  it.  We  now  have  exposed  to 
view  the  fascia  lata  of  the  thigh,  and  ascending 
on  its  inner  anterior  surface  the  major  saphena 
vein. 

Previous  to  proceeding  with  the  dissection 
and  description  of  these  parts,  Poupart's  liga- 
ment, or,  more  properly,  the  inguinal  ligament, 
and  its  connexions,  first  claim  our  notice. 

The  inguinal  ligament  arises  from  the  ante- 
rior superior  spinous  process  of  the  ilium,  and 
is  inserted  in  the  tuberosity  of  the  pubes,  into 
the  symphysis  pubis,  and  into  the  linea  ileo 
pectinea.  This  last  insertion  has  received  the 
name  of  Gimbernat's  ligament,  and  was  sup- 
posed to  be  the  seat  of  stricture  in  femoral 
hernia.  The  inguinal  ligament  is  a  firm  fibrous 
substance,  and  has  by  many  been  considered 
as  formed  by  the  interior  termination  of  the 
tendon  of  the  oblique  muscle  ;  by  others  it  has 
"been  considered  as  two  distinct  ligaments  ;  the 
superior  one  of  arounded  appearance,  extending 


40 


from  the  ilium  to  the  pubes,  retaining  its  origi- 
nal name  ;  and  the  inferior  one  inserted  by  Gim- 
bernat's  ligament  into  the  linea  ileo  pectinea> 
taking  the  name  of  crural  arch,  from  its  arched 
appearance,  and  under  which  the  great  vessels 
pass  out  from  the  abdomen.  This  division,  how- 
ever, would  seem  to  be  more  the  effect  of  the 
knife,  dividing  and  removing  the  cellular  sub- 
stance between  its  fibres,  than  from  airy  real 
existence. 

We  shall  consider  it  anatomically  as  one 
ligament,  retaining  however,  for  perspicuity., 
the  name  of  crural  arch,  as  more  immediately 
expressive  of  the  aperture  through  which  femo- 
ral or  crural  .hernia  protrudes.  The  inguinal 
ligament  has  three  processes,  viz.  the  fascia 
transversalis,  running  directly  upwards  between 
the  peritoneum  and  transversalis  muscle  ;  the 
fascia  lata,  running  downwards  and  investing 
the  muscles  of  the  thigh  ;  and  the  fascia  iliaca 
lining  the  iliacus  interims  muscle. 

We  can  now  proceed  to  the  removal  of  the 
fat  and  cellular  substance  immediately  about 
the  crural  arch,  feeing  careful  not  to  take  away 


41 


the  anterior  portion  of  the  sheath  of  the  femo- 
ral vessels.  All  the  dissection  necessary  being 
now  completed,  we  will  consider  the  processes 
of  the  inguinal  ligament. 

The  fascia  transversalis  has  already  been 
noticed  when  on  inguinal  hernia,  and  nothing 
more  remains  to  be  described,  with  the  excep- 
tion of  a  process  sent  down  the  leg,  forming  the 
anterior  part  of  the  sheath  of  the  vessels,  which 
shall  be  more  particularly  spoken  of  when  on 
the  femoral  sheath. 

The  fascia  lata  is  a  thick  shining  mem- 
brane of  a  fibrous  structure,  enveloping  the 
muscles  of  the  thigh.  It  arises  from  the  spine 
of  the  ilium,  from  the  inguinal  ligamerit,  and 
from  the  arch  of  the  pubes,  and  is  divided  at  the 
upper  and  fore  part  of  the  thigh  into  two  por- 
tions, viz.  the  pectineal  or  pubic,  and  the  iliac 
portions  of  the  fascia  lata. 

The  pubic  portion  arises  from  the  arch  of  the 

pubes,  and  invests  the  gracilis  and  pectinalis 

muscles.  AH  that  part  of  it,  superior  to  the  point 

at  which  the  saphena  enters  the  femoral  vein, 

5 


42 


passes  inward  under  the  sheath  of  the  vessels, 
and  is  lost  among  muscular  fibre.  Inferiorly 
it  passes  under  the  saphena  on  the  face  of  the 
sheath  and  becomes  continuous  with  the  iliac 
portion. 

The  iliac  portion  arises  from  the  spine  of 
the  ilium,  runs  inwards  covering  the  sheath  of 
the  vessels,  and  terminates  in  an  abrupt  edge 
at  the  inguinal  ligament.  It  is  the  termination 
of  this  edge  interiorly  which  has  received  the 
name,  from  its  crescentic  or  falciform  appear- 
ance, of  crescentic  edge  oy  falciform  process  of 
the  fascia  lata,  It  is  about  two  inches  in  length, 
its  upper  horn  passes  down  by  the  inner  side  of 
the  femoral  sheath,  and  is  connected  to  Gim- 
bernat's  ligament ;  its  lower  horn  passes  under 
the  saphena  vein,  immediately  below  where  it 
terminates  into  the  femoral,  to  meet  its  fellow 
portion  of  the  opposite  side. 

It  can  now  be  readily  conceived  in  looking 
at  the  parts,  how  a  femoral  hernia  must  neces- 
sarily protrude  from  under  the  iliac  portion  and 
rest  upon  the  pubic. 


43 


The  fascia  iliaca  can  be  examined  next,  if 
desired,  or  it  can  be  left  for  a  more  advanced 
stage  of  the  dissection.  We  however,  to  finish 
the  fasciae,  will  describe  it. 

The  fascia  iliaca  arises  from  the  inner 
labium  of  the  crista  of  the  ilium,  and  from  all 
the  posterior  edge  of  the  inguinal  ligament, 
with  the  exception  of  that  part  forming  the 
crural  arch.  By  this  origin  from  the  iliac 
portion  of  the  inguinal  ligament,  or  that  space 
from  the  out3r  edge  of  the  sheath  to  the  spine 
of  the  ilium,  a  hernia  is  prevented  in  that 
direction ;  and  by  the  origin,  from  the  inner 
edge  of  the  crural  sheath  to  the  symphy- 
sis pubis,  a  space  is  left  between  the  two  for 
the  passage  of  the  femoral  vessels  to  descend 
to  the  thigh.  This  last  portion  of  the  fascia 
iliaca  is  continuous  with  the  fascia  transversalis, 
and  passes  down  into  the  cavity  of  the  pelvis 
to  be  attached  to  the  bladder. 

The  fascia  iliaca  has  its  posterior  surface 
in  contact  with  the  iliacus  internus  and  psoas 
magnus  muscles,  and  the  upper  part  of  the  ante- 
rior crural  nerve.     Its  anterior  surface  is  con- 


nected  with  the  iliac  vessels,  and  loosely  with 
the  peritoneum. 

The  only  particular  importance  attached  to 
this  fascia,  as  connected  with  hernia,  is  a  pro- 
cess sent  down  under  the  femoral  vessels,  form- 
ing, as  it  were,  a  floor  for  them  to  rest  on,  and 
which  joining  laterally  with  the  process  from 
the  fascia  transversalis,  makes  up  the  femoral 
sheath. 

The  fascia  lata  can  now  be  detached  from 
its  connexion  with  the  inguinal  ligament,  and 
carefully  turned  off,  that  the  femoral  sheath 
which  comes  next  to  be  examined,  may  be 
exposed. 

The  femoral  or  crural  sheath  is  a  mem- 
branous  canal  enclosing  the  femoral  vessels. 
It  is  formed  anteriorly  by  the  process  of  the 
fascia  transversalis,  and  posteriorly  by  that  of 
the  fascia  iliaca  ;  the  one  forming  the  roof, 
and  the  other  the  floor,  connected  at  the  sides. 

The  femoral  sheath,  by  its  superior  portion 
arising  from  the  circumference  of  the  arch  of  the 


45 


inguinal  ligament,  and  becoming  narrower,  and 
in  closer  contact  with  the  vessels,  as  it  proceeds 
down  the  thigh,  is  of  a  funnel  like  form. 

On  cutting  into  this  sheath,  we  can  distinctly 
see  that  it  is  a  regularly  circumscribed  cavity, 
convex  at  its  superior  surface  ;  we  can  also  see 
that  point  at  the  upper  and  forepart  about  an 
inch  and  a  half  from  its  commencement,  wrhere 
the  saphena  perforates  the  sheath  to  join  the 
femoral  vein, 

The  point  to  be  most  particularly  noticed, 
and  which  is  of  essential  importance  to  be  ac- 
quainted with  and  understood,  is  that  part  called 
the  cribriform  portion  of  the  femoral  sheath. 
It  is  situated  on  its  anterior  and  inner  surface 
a  little  below  the  crural  arch,  and  is  the  place 
at  which  the  subcutaneous  absorbents  of  the 
thigh  perforate  it,  to  enter  a  gland  lying  within 
this  canal. 

These  holes  are  about  twelve  in  number, 
and  the  portion  of  the  femoral  sheath  thus  per- 
forated, is  that  part  which  yields  to  the  pres- 
sure of  a  hernial  protrusion,  and  forms,  with 


46 

the  assistance  of  the  reticular  membrane,  the 
fascia  propria  of  a  femoral  hernia. 

All  that  now  remains  to  be  observed  within 
this  canal,  is  the  relative  situation  of  the  artery 
with  the  vein,  and  the  seat  of  the  crural  ring. 
The  femoral  artery  is  seen  occupying  the  outer 
boundary  of  the  sheath,  and  the  vein  lying  on 
the  inside  of  the  artery  nearly  in  the  centre,  and 
divided  from  it  by  a  septum  of  a  membranous 
structure. 

The  crural  ring  is  that  part  of  the  sheath 
seen  from  the  abdomen,  and  is  the  space  be- 
tween the  vein  and  Gimbernat's  ligament.  This 
is  occupied  by  the  glands  through  which  the 
absorbent  vessels  pass  into  the  pelvis,  and  is 
the  aperture  through  which  femoral  hernia  pro- 
trudes, and  the  seat  of  stricture  when  it  is 
strangulated. 

The  dissection  and  the  description  of  the 
individual  parts  of  femoral  hernia  being  now 
finished,  we  will  proceed  to  the  revision  of 
them,  as  they  are  respectively  situated  and  con- 
nected with  each  other. 


47 


OF  THE  GENERAL  ANATOMY  CONHTSCB* 
ED  WITH  FEMORAL  HERNIA, 

As  in  inguinal  hernia,  we  restore  the  parts 
to  their  natural  situation,  and  we  then  find  the 
following  arrangement : 

First,  the  common  integuments.  Secondly, 
the  fascia  superficialis.  Thirdly,  the  inguinal 
ligament  having  one  origin  from  the  spine  of 
the  ilium,  and  three  insertions,  viz.  into  the 
tuberosity  of  the  pubis,  into  the  symphysis 
pubis,  and  into  the  linea  ileo  pectinea,  forming 
Gimbernat's  or  the  femoral  ligament.  It  also 
has  three  processes,  the  fascia  transversalis, 
running  upwards ;  the  fascia  iliaca,  investing 
the  iliacus  internus  muscle  ;  and  the  fascia  lata, 
covering  the  muscles  of  the  thigh :  this  last 
consists  of  two  portions,  the  pubic  and  iliac ; 
the  pubic  covering  the  gracilis  and  pectinalis 
muscle,  the  iliac  covering  the  outer  and  ante- 
rior part  of  the  thigh,  and  terminating  at  the 
inguinal  ligament  in  a  falciform  manner,  mak- 
ing the  falciform  process  or  crescentic  edge  of 


48 


the  fascia  lata.  The  saphena  major  vein  is  seen 
ascending  on  its  surface,  and  terminating  in  the 
fe  moral  at  the  inferior  termination  of  the  cres- 
centic  edge. 

Next,  we  have  the  femoral  sheath  of  a  funnel 
like  form,  lying  under  the  iliac  portion  of  the 
fascia  lata,  and  made  up  anteriorly  of  a  process 
or  continuation  of  the  fascia  transversalis  down- 
wards, and  posteriorly  of  a  process  of  the  fascia 
iliaca  continued  in  the  same  direction.  In  the 
anterior  part  of  the  sheath,  we  find  the  cribri- 
form plate,  marking  the  entrance  of  the  absorb- 
ent vessels  to  a  gland  within  it.  We  are  also 
to  remember  that  from  the  weakness  of  this 
part,  from  its  numerous  perforations,  it  becomes 
together  with  the  reticular  membrane,  the 
covering  immediately  preceding  the  hernial 
sac,  constituting  the  fascia  propria. 

On  opening  the  crural  sheath,  we  observe  the 
relative  situation  of  the  vessels,  that  the  artery 
is  on  the  outside,  and  the  vein  on  the  inside, 
divided  by  a  septum  from  each  other,  and  that 
the  crural  ring,  occupied  by  glands,  is  the  space 
between  the  vein  and  Gimbernat's  ligament. 


49 


through  which  femoral  hernia  protrudes,  and 
by  which  it  is  strangulated. 

A  femoral  hernia  must  thus  have  for  its  co* 
verings  the  integuments,  the  fascia  superficialis, 
the  fascia  propria,  and  the  hernial  sac. 


OF  THE  OPERATION  FOB.  FS2MCOR.A& 
HBRZfXA, 

This  consists  in  making  a  transverse  inci- 
sion through  the  integuments  along  the  base  of 
the  tumour,  its  whole  length.  This  is  met  by 
another,  two  or  three  inches  in  length,  as  may 
be  required,  terminating  at  the  middle  of  the 
former  :  the  two  making  the  form  of  the  letter 
T  inverted. 

The  flaps  of  integuments  are  to  be  dissected 
off,  and  the  fascia  superficialis  then  removed  by 
similar  incisions.  We  now  have  reached  the 
fascia  propria,  which  in  a  similar  manner  is  to 
be  carefully  dissected  from  the  hernial  sac. 

6 


50 


The  knife  is  now  placed  flatwise,  and  a  small 
hole  cut  through  this  last  covering,  the  accom- 
plishment of  which,  the  escape  of  a  fluid  will 
most  probably  evince.  Should  this  not  occur, 
the  anatomy  of  the  parts  can  be  the  only  cau- 
tious guide. 

The  same  rules  and  caution  are  now  to  be 
observed  in  the  division  of  the  hernial  sac,  and 
dilatation  of  the  stricture,  as  mentioned  in  in- 
guinal hernia ;  that  of  introducing  a  director, 
and  placing  the  bistoury  within  its  groove,  and 
cutting  freely  outwards  ;  next,  introducing  the 
finger  to  the  seat  of  stricture,  keeping  the  pro- 
trusion behind  it,  and  introducing  the  probe 
pointed  bistoury  flatwise  upon  its  face,  and  then 
turning  it  upwards. 

The  stricture  in  this  protrusion  is  at  the 
crural  ring,  and  is  to  be  divided  upwards  and 
inwards ;  thus  the  epigastric  artery  and  the  fe- 
moral vein  are  avoided,  which  might  otherwise 
be  opened  and  be  of  serious  consequence. 

This  protrusion,  if  returnable,  is  to  be  return- 
ed in  the  same  manner  as  in  inguinal  hernia, 


51 


and  if  not,  must  then  take  its  chance  for  union 
by  adhesion,  or  an  artificial  anus  must  be  the 
consequence. 


Or  THIS  AWATOBSIT   COTTOTESCTSD   WITH 
UZHZBXLIC  AL  AITO  VSNT&AL  KEH3NTI.J5. 

The  dissection  of  the  parts  connected  with 
these  two  forms  of  hernia,  was  included  in  the 
same  performance  with  inguinal,  and  needs  no 
particular  description.  They  protrude  directly 
from  the  abdomen,  the  former  at  the  umbilicus, 
the  latter  at  any  point  not  peculiar  to  the  others, 
and  consequently  have  three  coverings ;  the 
common  integuments,  the  fascia  superficialis, 
and  the  peritoneal  hernial  sac. 

The  operation  for  their  relief  when  strangu- 
lated, must  be  governed  by  the  size  of  the  tu- 
mour. Generally  a  simple  incision  through  the 
integuments  in  the  long  axis  of  the  tumour,  and 
continued  successively  through  the  remaining 
coats  is  su fficient.  Sometimes,  when  large,  a 
T  incision  is  necessary,  and  when  still  larger, 
a  crucial  is  required. 


52 


The  division  of  the  stricture  must  be  govern- 
ed by  the  location  of  the  tumour,  having  a  par- 
ticular reference  to  the  course  of  the  epigas- 
tric artery. 

Pelvic  herniae  are  so  rare  as  to  require  no 
distinct  head  or  description. 


I  have  now  arrived  at  the  end  proposed  in  my  pre- 
face ;  but  it  would  be  doing  an  injustice  to  my  feelings 
to  conclude  this  essay,  without  acknowledging  the  obli- 
gations due  to  my  distinguished  preceptor,  Doctor 
Mott,  not  only  for  the  opportunities  afforded  me  of 
seeing  his  masterly  dissections,  and  hearing  his  scien- 
tific elucidations  of  the  subject  of  Hernia,  but  also,  of 
witnessing  his  operations  performed  for  it,  in  all  its 
various  forms. 

To  his  bright  example  I  owe  my  taste  and  desire  for 
surgical  knowledge ;  and  whilst  I  reflect  on  his  manly 
exertions  to  elevate  his  profession  to  the  highest  point 
of  excellence  and  public  usefulness,  I  can  never  want 
an  incentive  necessary  for  its  complete  acquirement. 

To  him  I  return  my  thanks,  and  shall  always  remem* 
ber  with  pleasure,  the  many  kind  attentions  1  have 
received  from  him  both  privately  and  publicly. 

THE  END. 


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